Expanding the indications for percutaneous mitral commmissurotomy in rheumatic mitral stenosis: look carefully at the commissures, and proceed cautiously and skilfully.

نویسنده

  • Francesco Maisano
چکیده

Percutaneous balloon mitral valve commissurotomy (PMC) was introduced by Inoue in the 1980s, as an alternative to surgical closedcommissurotomy. PMC is the first exampleof a transcatheter valve intervention replicating a surgical procedure, and the fact that Inoue is a surgeon underlines the influence of multidisciplinary efforts in the evolution of transcatheter therapies. Today PMC is the first-line therapy for most symptomatic patients with mitral valve stenosis with favourable clinical and anatomical characteristics (with a recommendation class IB by the latest European guidelines. The main objective of PMC is to delay surgery, particularly when this would imply the implantation of a valve prosthesis. In patients not amenable to PMC, in Western countries, closed mitral commissurotomy has been replaced by open mitral commissurotomy using cardiopulmonary bypass in selected patients. Subvalvar apparatus management is the main advantage of open commissurotomy leading to greater valve areas as compared with closed commissurotomy and with PMC in patients with papillo-commissural fusion. However, most patients with anatomy not amenable for PMC are also suboptimal candidates for surgical repair and mostly undergo valve replacement. Patient selection plays a key role in PMC, as is the case for other transcatheter interventions. More specifically, anatomical and clinical characteristics are predictive of early and long-term success of the percutaneous procedure. Echocardiography plays a central role in the contemporary decision-making process, and several scores have been developed to predict early and long-term outcomes of PMC. A contemporary focus of the pre-procedural echocardiographic screening for PMCshould include a meticulous analysis of the commissures. The commissures are the target of open surgical mitral repair: careful commissural opening, with splitting of the subvalvar apparatus is the main objective of surgery, and it is associated with long-term repair durability (Figure 1). Since commissural opening is the primary mechanism of increase of the mitral valve area, it is the main determinant of early and late clinical outcomes following PMC. However, commissural opening can also be associated with excessive mitral regurgitation, particularly in patients with more advanced pathology in the commissural area. It is interesting to note that most commonly used scoring systems do not incorporate commissural anatomy in the algorithm, while commissural thickening and calcification has been incorporated in more recent predictive scores. Outcomes in patients with commissural calcification are ambiguous, and the indication for PMC under these circumstances remains debated. The presence of commissural calcification is considered a relative contraindication to both PMC and surgery due to the risk of valve lesions and insufficient valve area increase. Sutaria et al. reported an extremely low procedural success rate of PMC ( 50%) in patients with significant commissural calcification, associated with unsatisfactory functional improvement. Asa consequence, theauthors suggest that in the presence of calcified commissures, surgery should be considered as first-line treatment. However,Dreyfus et al., in a series of 464 patients undergoingPMC in a contemporary time frame of 3 years in a high volume centre of excellence for mitral interventions, reported promising outcomes in patients with unfavourable commissural anatomy. Although the authorsobservedanexpected lowersuccessrate inpatientswithcommissuralcalcification,procedural successcouldstill beachieved inmost patients (threeoutof four)andnotat theexpenseofanexcessprocedural complication rate. Based upon this recent experience, the authors suggest that PMC should still be considered a first-line treatment of patients with severe mitral stenosis even in the presence of (unilateral) calcified commissures with otherwise favourable clinical characteristics. Severe bilateral calcification should be still considered an absolute contraindication to PMC. A limitation of the study is the short

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عنوان ژورنال:
  • European heart journal

دوره 35 24  شماره 

صفحات  -

تاریخ انتشار 2014